The CMG Voice

There have been many recent articles about the challenges presented by electronic medical records (EMR) to both health care providers and their patients. Many of the criticisms have to do with the extra time needed to input information to the EMR system and the temptation to simply click buttons rather than providing detailed information. The major purpose of medical records is to provide information to future providers to assist them in diagnosing and treating medical problems.

The over-riding criticism of EMR, however, is the tendency to “cut and paste” information. This means that early errors in clinical information get repeated over and over again and can provide a false basis for medical decision-making. It also means that each time someone inputs information into the system, the same paragraphs are repeated. This means that finding any new information in the EMR can be a frustrating effort to ignore all of the duplicate information and try to tease out the pertinent information.

A good example was a recent review by me of emergency department records for a man who had symptoms of a heart attack. The initial paragraph about the reasons for his ER visit was repeated every time someone put in new information, such as lab results or other test results. In the 100+ pages of the printed EMR records, I counted at least 20 instances of the same paragraph being reprinted. Finding the important lab or test results in the midst of this set of records required great attention. So how is the busy physician or nurse going to find that information in the middle of a busy morning in the ER?

A physician writing about EMR made the following comment: “[i]n the past week I received a USB drive with 2402 pages from a hospital chart. It took me less than 30 minutes to scan more than 2300 of those pages and eliminate them as absolutely useless. Page after page of information was either downloaded automatically from a monitor or created for nothing more than to comply with regulations. Less than 5% of the chart contained potentially usable information (emphasis added).” Yet it’s that 5% which may mean the difference between good care and the death of a patient. Any system that makes it difficult to find the useful information in a medical chart is a system that needs to be changed.

Gallup recently polled a number of Americans regarding how they perceived the honesty and ethical standards of various professions. The question was framed “Please tell me how you would rate the honesty and ethical standards of people in these different fields – very high, high, average, low or very low?”

Unsurprisingly, nurses were at the top again with 84% of those polled rating their honesty and ethical standards as “very high” or “High”. They have topped the list every year but one since this poll was introduced in 1999. Next on the list were pharmacists at 67% and medical doctors at 65%. Of note, chiropractors and psychiatrists checked in at 38%.

At the other end of the spectrum, 8% of those polled believed the honesty and ethical standards of members of Congress were Very High or High. That is worse than car salespeople (9%), insurance salespeople (9%), Business executives (17%) and, yes, lawyers (18%).

From the perspective of a medical malpractice attorney, this makes sense. Jurors tend to give the benefit of the doubt to the health care provider on trial for committing malpractice, and do the opposite to the plaintiff victim (and his or her attorney). But why is that?

One possible reason is motive. At the time that the alleged malpractice occurred, unless the doctor or nurse was drunk or on drugs, or otherwise should not be practicing medicine, he or she was trying to help the patient. It may be that in hindsight the treatment offered or diagnosis made was wrong, but those mistakes are “honest” because not only was there no malicious intent, one can infer there was benevolent intent.

Contrast that with the plaintiff, a person with his or her hand out asking for money from the doctor, sitting side by side with not only a lawyer, but a personal injury lawyer. The perception can easily be that their motives are not benevolent but fueled by anger, greed, or some combination of the two.

So much of a trial is a battle of which side is more credible. Reading polls such as this one from Gallup confirm my belief that these battles are tilted at the start.

You may have noticed an Urgent Care Clinic near you these days. It may be called something a little different, like Immediate or Express Care, but the template is essentially the same. These clinics have sprung up to fill a perceived gap in healthcare, available for folks who have healthcare needs that don’t rise to the level (in both time and cost) of an emergency room visit, or when it is inconvenient (or impossible) to see their primary care doctor (if they have one).

While there are certainly benefits to such clinics, there are potential pitfalls for patients. You can read more about what Urgent Care Clinics are, who staffs them, who goes there for treatment, and what possible medical/legal issues there are arising from such treatment here:

In a recent article in Journal of Patient Safety, it was reported that fewer than 2% of physicians were accountable for more than 50% of all settlements made in medical malpractice cases. The analysis used data from the National Practitioner Data Bank, a federal law that requires that all medical malpractice settlements, of any amount, have to be reported to the Data Bank.

It was set up so that doctors would not be able to move from state to state and avoid scrutiny of their malpractice histories. Any hospital to which a doctor applies for admitting privileges has to contact the Data Bank in order to find out about the doctor’s claims history. It is not open for inquiries from the public, however.

The article pointed out that only a small percentage of the physicians whose reported claim payouts were recorded in the Data Bank lost clinical privileges or were subject to licensing board action. In another study a year ago, it was found that 1% of doctors were responsible for 32% of paid claims. The conclusion: even with easy access to date showing that a few physicians are harming patients at a much higher rate that others physicians, our state medical disciplinary boards are doing little to protect those patients.

With the new Republican administration, it is unlikely that situation will change. Tom Price, M.D., the new Secretary of Health and Human Services, has frequently lambasted what he calls “lawsuit abuse,” and vows to enact laws that would prevent hospitals from reporting a claim to the Data Bank unless there have been hearings to protect the doctor.

He also will push laws to require “higher standards of evidence” for malpractice claims. This would make it even more difficult for such claims to be brought. At it is, of medical malpractice cases going to trial, fewer than 10% result in verdicts for the claimant. The health care providers win more than 90% of the lawsuits that are brought. Because of the high risk and cost of going to trial, attorneys in this area of law practice consider only a few claims to pursue.

If you’ve been to an ER or hospital and had a doctor see you, you may have seen another person follow the doctor into the room. That person may have been a scribe, whose job it is to write down what is said so that the doctor can go back and create an accurate medical chart note reflecting the encounter.

However, a new model of charting has popped up, one in which the doctors are wearing Google Glasses and the scribes aren’t next to them in the room, but remote.

The company who designed the model, Augmedix, argues that its remote scribe model makes the whole process better. First it cuts down on costs: it’s 25-50% cheaper than the in-person model. Second, it saves a doctor time at the end of the day creating the chart note, since the remote scribe will create the substance of the note, and the doctor needs only review and sign off on it. Third, the scribe can actually provide the doctor information about the patient, including what medications the patient is taking, what recent lab results were, and the like. That information is displayed on the Google Glass instead of the doctor having to turn his or her back on the patient and look at a computer screen in the room. This allows the doctor to remain engaged with the patient.

In person scribes also have the typical problems associated with any worker: they call in sick, they aren’t available during the hours that are needed, and they take up physical space. With this more centralized model, Augmedix argues the scribe service is more consistent.

At least one study has shown that cardiologists who tried the model saw slightly more patients (9.6%) than those who used the traditional in-person scribe model. There have been no studies to see whether the patients’ experience is better, or that patient outcomes improve.